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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 1  |  Page : 26-34

Comparative evaluation of effectiveness of sodium fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) in treating postoperative sensitivity associated with in-office vital tooth bleaching: A clinical study


Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur, Punjab, India

Date of Web Publication25-May-2017

Correspondence Address:
Prashant Monga
Department of Conservative Dentistry and Endodontics, Genesis Institute of Dental Sciences and Research, Ferozepur - 152 002, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/endo.endo_118_16

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  Abstract 

Aim: To clinically compare the effectiveness of sodium fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) in reducing postoperative sensitivity associated with in-office vital tooth bleaching.
Materials and Methods: In-office vital tooth bleaching was performed on 45 patients using 40% hydrogen peroxide gel in a single visit. After the procedure, the patients were randomly divided into three study groups based on the use of desensitizing agent: Group 1 - experimental gel without desensitizing agent (n = 15), Group 2 - cream with 1.1% sodium fluoride (n = 15), and Group 3 - cream with 10% CPP-ACP (n = 15). Gel or cream assigned for each patient was applied directly on the labial surfaces of teeth and left undisturbed for 3 min. Furthermore, the patients were asked to apply the agent given to them for 3 min twice daily after brushing for 14 days. Follow-up was done on 3rd, 7th, and 14th day, at which time tooth shade changes was assessed using a value-oriented Vita classic shade guide. The incidence, duration, and intensity of tooth sensitivity experienced were self-assessed on a daily basis for the 14-day study period using a visual analog scale.
Results: Significant higher incidence and intensity of tooth sensitivity was found in experimental gel without desensitizing agent in comparison to sodium fluoride and CPP-ACP groups. Significant decrease in Vita classic tab values was seen in experimental gel group after 14 days; however, in sodium fluoride group, tab change was not significant.
Conclusion: Sodium fluoride and CPP-ACP both reduced incidence and intensity of tooth sensitivity after tooth bleaching. Sodium fluoride showed better shade stability than CPP-ACP; however, the difference was not significant.

Keywords: Casein phosphopeptide-amorphous calcium phosphate; hydrogen peroxide; sodium fluoride; tooth bleaching; tooth sensitivity.


How to cite this article:
Singh M, Mahajan P, Monga P, Mahajan S, Singla D, Kaur N. Comparative evaluation of effectiveness of sodium fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) in treating postoperative sensitivity associated with in-office vital tooth bleaching: A clinical study. Endodontology 2017;29:26-34

How to cite this URL:
Singh M, Mahajan P, Monga P, Mahajan S, Singla D, Kaur N. Comparative evaluation of effectiveness of sodium fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) in treating postoperative sensitivity associated with in-office vital tooth bleaching: A clinical study. Endodontology [serial online] 2017 [cited 2019 Sep 21];29:26-34. Available from: http://www.endodontologyonweb.org/text.asp?2017/29/1/26/206998




  Introduction Top


Tooth bleaching is one of the most popular cosmetic dental procedures opted by the patients who desire pleasing smile.[1] Discolored teeth differ variably in appearance and severity. Detailed clinical examination and appraisal of the patient's oral hygiene practices and dietary habits help in coming to diagnosis of the cause of tooth discoloration and accordingly the type of corrective procedure required.[2] Tooth bleaching is the simplest, least invasive means available to lighten discolored vital teeth.

Hydrogen peroxide (H2O2) is the most commonly used bleaching agent for in-office vital tooth bleaching. Typically, peroxide concentrations of in-office bleaching products range from 25% to 38%.[3] One of the most frequent adverse effects of vital tooth bleaching is sensitivity. It represents as a generalized sensitivity but may also occur as a spontaneous, sharp, shooting, or tingling pain limited to one or few teeth.[4]

The incidence of tooth bleaching sensitivity can be as high as 60%.[5] Sensitivity with in-office bleaching may be attributed to high concentration of peroxide applied. The majority of people are able to tolerate tooth bleaching well. Yet, sensitivity related to tooth bleaching is a critical problem for some patients.

A number of desensitizing agents have been tried in an attempt to counteract bleaching-related sensitivity. Combination of potassium nitrate and fluoride had been used by manufacturers, to reduce sensitivity experienced by patients. Sodium fluoride works on the principle of tubular occlusion, and the fluoride component is thought to reduce the solubility of dentin, thus helps in reducing sensitivity. The effect of fluoride on tooth sensitivity, however, remains controversial.[6]

Tooth mousse is a sugar-free water-based cream that contains 10% casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) and has sealing effect on dentinal tubules. It has been proposed that CPP-ACP can exert a rapid desensitizing effect through immediate protein binding, followed by the deposition of calcium and phosphate compounds within exposed dentin tubules.

As there is no consensus regarding effectiveness of sodium fluoride and CPP-ACP in reducing sensitivity after tooth bleaching, this study has been undertaken to clinically compare the effectiveness of two types of desensitizing agents (sodium fluoride and CPP-ACP) in reducing postoperative sensitivity associated with in-office vital tooth bleaching.


  Materials and Methods Top


Forty-five volunteers who met the inclusion and exclusion criteria [Table 1] signed a consent form containing all the information regarding the risks and benefits of the treatment and participated in the study to the end.
Table 1: Inclusion and exclusion criteria

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Before clinical examination, a case sheet and history form were filled for each patient to record all information regarding age, sex, medical and dental history, dentifrice being used, history of any habits (especially smoking), and history of sensitivity or previous bleaching.

Selected patients received full-mouth prophylaxis 2 weeks before the bleaching appointment. Fifteen patients each were randomly assigned to three study groups according to the type of agent used.

Figure 1: Pre-operative (Group 1)

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Figure 2: Application of gingival barrier (Group 1)

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Figure 3: Application of bleaching agent (Group 1)

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Figure 4: Post operative (Group 1)

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Figure 5: Application of Desensitizing agent (Group 1)

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Figure 6: Desensitizer dispensed in unmarked syringe (Group 1)

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Figure 7: Follow up 3rd Day (Group 1)

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Figure 8: Follow up 7th Day (Group 1)

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Figure 9: Follow up 14th Day (Group 1)

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Figure 10: Pre-operativee (Group 2)

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Figure 11: Application of gingival barrier (Group 2)

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Figure 12: Application of bleaching agent (Group 2)

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Figure 13: Post operative (Group 2)

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Figure 14: Application of Desensitizing agent (Group 2)

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Figure 15: Desensitizer dispensed in unmarked syringe (Group 2)

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Figure 16: Follow up 3rd Day (Group 2)

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Figure 17: Follow up 7th Day (Group 2)

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Figure 18: Follow up 14th Day (Group 2)

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Figure 19: Pre-operative (Group 3)

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Figure 20: Application of gingival barrier (Group 3)

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Figure 21: Application of bleaching agent (Group 3)

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Figure 22: Post operative (Group 3)

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Figure 23: Application of Desensitizing agent (Group 3)

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Figure 24: Desensitizer dispensed in unmarked syringe (Group 3)

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Figure 25: Follow up 3rd Day (Group 3)

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Figure 26: Follow up 7th Day (Group 3)

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Figure 27: Follow up 14th Day (Group 3)

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Tooth shade was evaluated using the Vitapan classical shade guide (Vita Zahnfabrik, Bad Sackingen, Germany) by cross-matching the middle third of labial surface of the maxillary anterior teeth in natural light. A lip and cheek retractor was placed. Preoperative photograph was taken while holding selected shade tab against central incisors [Figure 1], [Figure 10], and [Figure 19]. The gingival tissues of the teeth to be bleached were isolated using a light cure resin dam (Prevest DenPro Limited, India) to prevent the contact of bleaching gel with the gingival tissue [Figure 2], [Figure 11], and [Figure 20]. The bleaching agent (Opalescence Boost PF 40%, Ultradent Products, South Jordan, UT) was applied to labial surfaces of selected maxillary teeth using an applicator tip [Figure 3],[Figure 12] and [Figure 21]. The bleaching agent was washed away and a second application was done after 20 min during the 40-min application period, as per the manufacturer's instructions.

After two applications, the bleaching agent and gingival barrier were removed. Teeth were thoroughly rinsed and postbleaching shade was determined and recorded using Vitapan classical shade guide in natural light. Postoperative photograph was taken again [Figure 4],[Figure 13] and [Figure 22].

A pea-sized amount of the assigned desensitizing agent was applied directly on the labial surface of each tooth and left undisturbed for 3 min; care was taken to cover the entire labial surface and carried interproximally as much as possible [Figure 5],[Figure 14] and [Figure 23].

Desensitizing agents were removed using cotton and the patients were instructed to avoid rinsing, eating, or drinking for 30 min. Each patient was given the assigned agent in an unmarked syringe and was instructed to use the agent in a similar manner twice daily, once in the morning and once at night, after brushing their teeth for 14 days [Figure 6], [Figure 15], and [Figure 24].

Patients were scheduled for lower arch bleaching after 14 days.

Postbleaching sensitivity was evaluated by relying on patient's response to pain. All patients were given sensitivity sheets to record the postbleaching sensitivity of the teeth on a daily basis according to the visual analog scale (VAS) of pain for 14 days. Patients were also asked to record the stimulus that caused sensitivity, whether hot, cold, or any other stimulus.

The duration of pain, in seconds, minutes, or hours, was also recorded for the 14-day follow-up period. For descriptive analysis purpose, the pain intensity results were categorized according to the following scale: 0 = none, 1–3 = mild, 4–6 = moderate, and 7–10 = severe.

Follow-up of patients was done on the 3rd day [Figure 7], [Figure 16], and [Figure 25], 7th day [Figure 8], [Figure 17] and [Figure 26], and 14th day [Figure 9], [Figure 18], and [Figure 27]. Tooth shade evaluation was done again on every follow-up visit using Vitapan classical shade guide and shade was recorded.

Sensitivity sheets were collected from the patients on the 14th day and scheduled lower arch bleaching was carried out.

Statistical analysis was done using Chi-square test to compare the pain among the groups at time periods. The Kendall's tau test was used to compare the change in pain from day 1 to day 2 within the groups. The one-way analysis of variance (ANOVA) was used to compare the intensity and Vita classic tab values among the groups at time periods. The paired t-test was used to compare the mean change in sensitivity from day 1 to subsequent time periods. The repeated measures of ANOVA were used to find the effect of time and group interaction in the change in intensity and Vita classic tab values. P < 0.05 was considered statistically significant. All the analysis was carried out on SPSS 16.0 version (IBM, SPSS Inc., Chicago, USA).


  Results Top


Incidence of tooth sensitivity

Comparison of number of patients with pain from day 1 to day 2 within the groups is shown in [Table 2]. In Group 1, higher incidence of pain (86.7%) was seen in comparison to other groups. There was significant (P = 0.001) decrease in number of patients experiencing pain in Group 2 (46.7%) and Group 3 (53.3%) from day 1 to day 2. However, difference between Group 2 and Group 3 was not significant.
Table 2: Comparison of number of patients with pain from day 1 to day 2 within the groups

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Intensity of tooth sensitivity

Comparison of intensity level of pain among the groups across different time periods is shown in [Table 3]. The intensity of pain was observed to be significantly (P = 0.02) higher in the patients of Group 1 (experimental gel), as compared to Group 2 (1.1% sodium fluoride) and Group 3 (10% CPP-ACP) on day 3. No significant difference was seen in the intensity of pain between Group 2 and Group 3. Lowest intensity of pain was observed in Group 2 on day 1 and day 3. However, no significant difference was seen between groups on 7th day and 14th day.
Table 3: Comparison of intensity level of pain (based on visual analog scale) among the groups across the time periods

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Duration of tooth sensitivity

Comparison of number of patients experiencing sensitivity for different durations between the groups from day 1 to day 3 is shown in [Table 4]. Results showed no significant (P > 0.05) difference in the duration of sensitivity between the groups on day 1. There was significant (P = 0.001) decrease in duration of sensitivity in both Group 2 and Group 3 from day 1 to day 3. However, difference between Group 2 and Group 3 was not significant.
Table 4: Comparison of duration of sensitivity at different time periods among the groups

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Tooth shade stability

The recorded shades using the Vitapan shade guide showed that the smallest number of shade tab changes was three tabs and the largest was eight tabs. [Table 5] shows the comparison of Vita classic tab among the groups across the time periods. There was no significant (P > 0.05) difference in Vita classic tab values at day 1 and day 3 among the groups. However, significant decreases in tab values were seen in Group 1 (experimental gel) on 7th day and 14th day. Group 2 (1.1% sodium fluoride) showed lowest tab changes from 1st day to 14th day.
Table 5: Comparison of Vita classic tab values among the groups across the time periods

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  Discussion Top


Rapid lightening of tooth shade is the main advantage of in-office tooth bleaching, but sometimes, transient and intolerable sensitivity can be a drawback associated with this procedure. To overcome this drawback, different desensitizing agents are used in an attempt to prevent, or at least reduce, the intensity of sensitivity to an acceptable level for patients.[7]

The physiology of dental sensitivity after bleaching remains unclear due to the functional and structural complexity of teeth, including nerves, odontoblastic features, and internal movements of fluids.[8]

Most of the patients (95.6%) experienced sensitivity after tooth bleaching as 40% H2O2 was used. Results of this study are in agreement with those of some other studies that show high occurrence of sensitivity after concentrated peroxide-based bleaching. Maghaireh et al. reported that 98% of participants experienced sensitivity after using concentration of 35% H2O2 for bleaching.[7] Tang and Millar reported that 85.2% of their study participants had sensitivity after in-office bleaching using 15% H2O2.[9] Tay et al. used 35% H2O2 for vital tooth bleaching and reported that 66.8% participants experienced tooth sensitivity.[4]

In the present study, experimental gel without desensitizing group showed significantly higher incidence of tooth sensitivity than fluoride group and CPP-ACP group. When comparing the incidence of tooth sensitivity among the fluoride group and CPP-ACP group, there was no statistically significant difference in the incidence of pain. The present study is in agreement with the study conducted by Armênio et al., where the use of 1.23% sodium fluoride for 4 min after the application of 16% carbamide peroxide reduces or eliminates the incidence of sensitivity compared with the placebo group.[10]

The difference in the incidence of pain in the current study is also in agreement with the study, where placebo group showed more incidence of postbleaching tooth sensitivity than CPP-ACP group.[11]

In this study, postbleaching pain was recorded using VAS. The VAS is a horizontal line containing 10 numbers from 0 to 10; zero indicates no pain and 10 indicates the worst pain. Patients are asked to rate their pain along the line that best represents the intensity of their pain. The intensity results were categorized according to the following scale: 0 = none, 1–3 = mild, 4–6 = moderate, and 7–10 = severe. The VAS is more sensitive than other measures, especially those with a limited number of response categories.

In this study, the intensity of pain was observed to be significantly (P = 0.02) higher in the patients of experimental group as compared to fluoride group and CPP-ACP group. No significant difference was seen in the intensity of pain between fluoride group and CPP-ACP group. However, lowest intensity of pain was observed in fluoride group. The results of the present study are in agreement with the study, where 1.23% sodium fluoride had a significant effect in lowering sensitivity intensity compared with the placebo group when applied in the tray for 4 min after 16% carbamide peroxide whitening.[10]

Giniger et al. found that the use of 0.5% CPP-ACP with 16% carbamide peroxide mixed immediately before application proved to be significantly effective in reducing the intensity of tooth sensitivity during treatment and 5 days after treatment.[12]

Fluoride application has also been traditionally used to manage sensitivity, and it is thought to act as tubule blocker to control the pulpal fluid flow. The primary mechanism of action of fluoride is the occlusion of dentinal tubules or an increase in enamel hardness.[10]

CPP-ACP, a remineralizing agent developed to remineralize teeth and reverse early enamel carious lesion, is shown to make teeth less sensitive to hot, cold, air pressure, and tactile stimulation when it is applied topically either by dental professionals or by the patient themselves after tooth bleaching.[12] CPP-ACP may interfere with the penetration of oxidizing molecule during bleaching procedure as it is a remineralizing agent.

In the current study, it was found that in all test groups, more than half of the patients experienced sensitivity that lasted for seconds on 1st day. Forty percent of patients experienced sensitivity that lasted for seconds on 2nd day. Twenty-nine percent of total patients experienced sensitivity for minutes on 1st day and 22% of patients on 2nd day. In both fluoride and CPP-ACP groups, more patients reported sensitivity that lasted for seconds than for minutes. However, in experimental group without desensitizing agent, more patients experienced sensitivity that lasted for minutes.

Tooth shade evaluation was performed using the Vitapan classical shade guide (Vita Zahnfabrik, Bad Sackingen, Germany) by matching the middle third of the maxillary anterior teeth in natural light. The 16 shade tabs in the shade guide were numbered from 1 (lightest value, B1) to 16 (darkest value, C4), and the total tab change was calculated by subtracting the tab number corresponding to the baseline shade from that the tab number of the shade at each evaluation. Tooth shade was recorded at the baseline (before bleaching), directly after bleaching, and at days 3, 7, and 14 after bleaching. Patients in this study had a significant shade improvement after bleaching. An average of 4.49 units of tooth shade change was seen on 1st day. On 3rd day, average shade change improved from 4.49 to 4.62 units, probably because of the temporary dehydration effect, which lasts up to 72 h. This was followed by minor relapse on the 7th day in the experimental gel without desensitizing agent group and the CPP-ACP group; the shade relapse was less noticeable in the fluoride group.

On 14th day, average shade change was equivalent to average shade change on the 1st day, for fluoride group and CPP-ACP group. Shade was found to be darker on the 14th day in the experimental gel group. Fluoride group had a better shade stability compared with the CPP-ACP group, but difference between them was not significant. It has been shown that fluoride increases enamel hardness and renders it less permeable, which can explain why the patients in the fluoride group had a better shade stability than experimental gel without desensitizing and CPP-ACP groups.


  Conclusion Top


Within the limitations of this study, the following conclusions can be drawn:

  1. Higher incidence of tooth sensitivity was found in experimental gel without desensitizing agent group in comparison to other groups after tooth bleaching. However, no significant difference was found between sodium fluoride and CPP-ACP groups
  2. Significant decrease in duration of sensitivity was seen in both sodium fluoride group and CPP-ACP group. However, no significant difference was found between sodium fluoride group and CPP-ACP group
  3. Both sodium fluoride and CPP-ACP reduced intensity of tooth sensitivity to moderate level. However, sodium fluoride showed lowest pain intensity when used as desensitizer after tooth bleaching
  4. Sodium fluoride showed better shade stability followed by 10% CPP-ACP gel while experimental gel without desensitizing agent showed lowest shade stability.
.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zekonis R, Matis BA, Cochran MA, Al Shetri SE, Eckert GJ, Carlson TJ. Clinical evaluation of in-office and at-home bleaching treatments. Oper Dent 2003;28:114-21.  Back to cited text no. 1
    
2.
Hattab FN, Qudeimat MA, al-Rimawi HS. Dental discoloration: An overview. J Esthet Dent 1999;11:291-310.  Back to cited text no. 2
    
3.
Basting RT, Amaral FL, França FM, Flório FM. Clinical comparative study of the effectiveness of and tooth sensitivity to 10% and 20% carbamide peroxide home-use and 35% and 38% hydrogen peroxide in-office bleaching materials containing desensitizing agents. Oper Dent 2012;37:464-73.  Back to cited text no. 3
    
4.
Tay LY, Kose C, Loguercio AD, Reis A. Assessing the effect of a desensitizing agent used before in-office tooth bleaching. J Am Dent Assoc 2009;140:1245-51.  Back to cited text no. 4
    
5.
Hewlett ER. Etiology and management of whitening-induced tooth hypersensitivity. J Calif Dent Assoc 2007;35:499-506.  Back to cited text no. 5
    
6.
Olusile AO, Bamise CT, Oginni AO, Dosumu OO. Short-term clinical evaluation of four desensitizing agents. J Contemp Dent Pract 2008;9:22-9.  Back to cited text no. 6
    
7.
Maghaireh GA, Alzraikat H, Guidoum A. Assessment of the effect of casein phosphopeptide-amorphous calcium phosphate on postoperative sensitivity associated with in-office vital tooth whitening. Oper Dent 2014;39:239-47.  Back to cited text no. 7
    
8.
Nair PN, Luder HU, Schroeder HE. Number and size-spectra of myelinated nerve fibers of human premolars. Anat Embryol (Berl) 1992;186:563-71.  Back to cited text no. 8
    
9.
Tang B, Millar BJ. Effect of chewing gum on tooth sensitivity following whitening. Br Dent J 2010;208:571-7.  Back to cited text no. 9
    
10.
Armênio RV, Fitarelli F, Armênio MF, Demarco FF, Reis A, Loguercio AD. The effect of fluoride gel use on bleaching sensitivity: A double-blind randomized controlled clinical trial. J Am Dent Assoc 2008;139:592-7.  Back to cited text no. 10
    
11.
Nanjundasetty JK, Ashrafulla M. Efficacy of desensitizing agents on postoperative sensitivity following an in-office vital tooth bleaching: A randomized controlled clinical trial. J Conserv Dent 2016;19:207-11.  Back to cited text no. 11
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12.
Giniger M, Macdonald J, Ziemba S, Felix H. The clinical performance of professionally dispensed bleaching gel with added amorphous calcium phosphate. J Am Dent Assoc 2005;136:383-92.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24], [Figure 25], [Figure 26], [Figure 27]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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